Irene Mueller, EdD, RHIA 1

Basic ICD-9-CM Dx Coding, Part III Basic ICD-9-CM Coding Part III Compliance & Stds April 20, 2007 10 am 12 noon MST Irene Mueller, EdD, RHIA Montana Hospital Association Tele-Video MT-NC Spring 2007 Part III Objectives ability to understand; Compliance laws relating to coding, Ethical dilemmas in coding, and Coding standards Credentials CCA CCS CCS-P 4/20/07 Schedule 10 am 10:05 Introductions/Overview of day 10:05 10:50 Coding Compliance 10:50 11 am Break 11:00-11:45 Coding Ethics/Standards Coding Credentials 11:45-12:00 noon Questions Irene Mueller, EdD, RHIA 1

Basic ICD-9-CM Dx Coding, Part III Coding Compliance Hospitals must establish adequate internal control procedures to ensure that claims are submitted accurately edits (unbundled codes, wrong codes, pt age/sex) compliance warnings (upcoding) reimbursement (legitimate reimbursement opportunities - optimal) Audits (100% retrospective review, external) and reporting Monitoring (concurrent sample, internal), tracking data flow Continuing Education/Training HIPAA of 1996 Created Health Care Fraud and Abuse Control Program for MC, MA, and private industry OIG and Dept of Justice have power to enforce federal, state, and local laws to control healthcare fraud and abuse conduct investigations and audits pertaining to delivery and payments for healthcare services HIPAA penalties Criminal penalties for providers who knowingly and willfully attempt defraud up to 10 years in prison up to 20 years if serious injury to pt up to life if death of patient results Irene Mueller, EdD, RHIA 2

Basic ICD-9-CM Dx Coding, Part III HIPAA penalties Civil penalties $10,000 for EACH item or service billed fraudulently levied against providers, not individual employees HIPPA fraudulent activities 2 new practices added to civil fraudulent activities engaging in a pattern of coding that the person knows or should know will result in inappropriately higher payments (unbundling, fragmenting) submitting a claim for a medical item or service that the person knows or should know is not medically necessary Coder knows or should know How do you know every rule & regulation? US Govt publishes all proposed and final rules & regulations in daily Federal Register http://www.gpoaccess.gov/fr/index.html Therefore you have been told and you are now responsible! Irene Mueller, EdD, RHIA 3

Basic ICD-9-CM Dx Coding, Part III Assumption Coding Assignment of codes based on assuming (after review of the record) that pt has certain dx or requires certain proc w/o specific documentation by provider Types of Assumption Coding Unbundling Upcoding Overcoding Jamming Downcoding Types of Assumption Coding Unbundling; reporting multiple codes when a combination code exists Upcoding; reporting codes not supported by documentation Overcoding; reported codes for signs, symptoms, AND established diagnosis Jamming; routinely assigning 0 or 9 as 4 th or 5 th digit instead of the appropriate code (coding from the index) Downcoding; reporting lower-level codes as a convenience Avoid Assumption Coding Assignment of codes based on assuming (after review of the record) that pt has certain dx or requires certain proc. w/o specific documentation by provider Creates risk of fraud and abuse Need to use physician query process Physician Query Guidelines Irene Mueller, EdD, RHIA 4

Basic ICD-9-CM Dx Coding, Part III Physician Query Process Query based on clinical documentation Concurrent or Retrospective? Designate Contact person for process Use a query form Ask open-ended questions to avoid leading the physician Decide how to file Part of record = subject to disclosure Administrative = not subject to disclosure Need Dr documentation addendum in MR Physician Query Forms To obtain copies of sample physician queries and procedures, sample physician query forms, and physician query and medical record addendum forms, visit MC QIO for Oregon (OMPRO) Web site at www.ompro.org, click on Coding and Documentation Resources. Source: Micheletti, Julie A., Shlala, Thomas J.. "Documentation Rx: Strategies for Improving Physician Contribution to Hospital Records." Journal of AHIMA 77, no.2 (February 2006): 66-68. Physician Query??? Pt admitted with SOB, chest pain, fever PE rhonchi, wheezing, rales Lab sputum culture shows gramnegative bacteria Final dx viral pneumonia Should coder assign 480.9 or 482.83? Do you need to complete Physician Query? Irene Mueller, EdD, RHIA 5

Basic ICD-9-CM Dx Coding, Part III $ consequences in Inpt 480.9 = about $2,500 482.83 = about $3,500 Loss of $1,000 to facility Example Pt presents to ED w/cc of severe facial pain and headache Radiologist interpretation of x-ray is frontal sinusitis ED Dr documents dx of headache, facial pain, and sinusitis You should code? Example Pt present to Dr s office w/cc of nose lesion Lesion is removed in office and sent to path Pt scheduled for appt in 2 weeks Dx is lesion of the nose Path report is in record when coded Pathologist document actinic keratosis You should code? Irene Mueller, EdD, RHIA 6

Basic ICD-9-CM Coding Part III Compliance & Stds April 20, 2007 10 am 12 noon MST Irene Mueller, EdD, RHIA Montana Hospital Association Tele-Video MT-NC Spring 2007 Break Time Coding Ethics/Standards Coders represented in the Cooperating Parties by AHIMA As professionals have code of standards Credentialing process CCA (entry-level coder) CCS, CCS-P RHIT (CCA) RHIA (CCA) continuing education mandatory Irene Mueller, MLS, RHIA 1

HC Ethics Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. Hippocrates, 460 BC Source: http://www.sjsu.edu/depts/museum/hippoc.html Accessed: 2/13/07 AHIMA Code of Ethics Advocate, uphold and defend the individual's right to privacy and the doctrine of confidentiality in the use and disclosure of information. Put service and the health and welfare of persons before self-interest and conduct themselves in the practice of the profession so as to bring honor to themselves, their peers, and to the health information management profession. Preserve, protect, and secure personal health information in any form or medium and hold in the highest regard the contents of the records and other information of a confidential nature, taking into account the applicable statutes and regulations. www.ahima.org AHIMA Stds of Ethical Coding In this era of payment based on diagnostic and procedural coding, the professional ethics of coding professionals continue to be challenged. A conscientious goal for coding and maintaining a quality database is accurate clinical and statistical data. The following standards of ethical coding, developed by AHIMA's Coding Policy and Strategy Committee and approved by AHIMA's Board of Directors, are offered to guide coding professionals in this process. http://www.ahima.org/infocenter/guidelines/standards.asp Irene Mueller, MLS, RHIA 2

Compliance vs. Ethics How are ethics different from compliance? Ethics encourage good conduct. They are based on self-imposed standards, such as a Code. An ethics program is motivated by self-improvement and is based on principles and values. It seeks to help define what you should do. Compliance programs strive to prevent bad or criminal behavior. Because legal compliance is the goal, compliance programs are usually externally imposed. The motivation is to avoid penalties and punishment, and the reinforcement is all about what you can t do. Compliance vs. Ethics Compliance programs are the floor, not the ceiling. They outline minimal behaviors, not the best - there may still be room for unethical conduct. Compliance programs rarely address the root causes of misconduct, and they don t inspire human excellence. HIM professionals are actively involved in our organization s compliance programs. We need to understand, however, that ultimately, we should be striving for organizationwide ethics programs for our healthcare organizations. Enlightened healthcare organizations are going beyond compliance by encouraging an ethics program. AHIMA Coding Credentials Credentialing process CCA (entry-level coder) CCS, CCS-P RHIT (CCA) RHIA (CCA) continuing education mandatory http://www.ahima.org/certification/ Irene Mueller, MLS, RHIA 3

CCA The CCA should be viewed as the starting point for an individual entering a new career as a coder. The CCS and/or CCS-P exams demonstrate the mastery level skills that the CCA would strive for to advance his or her career. CCA Competencies Health Records and Data Content HI Requirements and Stds Clinical Classification Systems Reimbursement Methodologies Information and Communication Technologies Privacy, Confidentiality, Legal, and Ethical Issues Clinical Classification Systems Utilize electronic applications (encoders) Assign principal or 1 st -listed ICD-9-CM codes Assign 2ary dx ICD-9-CM codes, including CCs Assign principal and 2ary procedures Assign procedure codes using CPT Assign appropriate HCPCS codes ID discrepancies between coded data & supporting documentation Consult reference materials to facilitate code assign. Irene Mueller, MLS, RHIA 4

CCS Certified Coding Specialists are professionals skilled in classifying medical data from patient records, generally in the hospital setting. They review patients' records and assign numeric codes for each diagnosis and procedure. They must possess expertise in ICD-9-CM and the surgery section of CPT. In addition, CCSs know medical terminology, disease processes, and pharmacology. Accordingly, the CCS credential demonstrates tested data quality and integrity skills in a coding practitioner. The CCS certification exam assesses mastery or proficiency in coding rather than entry-level skills. CCS-P The CCS-P has expertise in physician-based settings such as physician offices, group practices, multi-specialty clinics, or specialty centers. A CCS-P reviews patients' records and assigns codes for diagnoses and procedures, which requires in-depth knowledge of CPT and familiarity with ICD- 9-CM and HCPCS Level II coding The CCS-P is expert in HI documentation, data integrity, and quality. Because coded data are submitted to insurance companies or the government for reimbursement, the CCS-P plays a critical role in the health provider's business operation. The CCS-P certification exam assesses mastery or How did you code the Goofy MR? proficiency in coding rather than entry-level skills. Irene Mueller, MLS, RHIA 5

Question from last time We had a question from one of our MDS nurses regarding a diagnosis of Sundowner's Syndrome? We were wondering if the code 296.90 would be the correct code to use? Thanks for your help. People with diseases such as Alzheimer's often have behavior problems in the late afternoon and evening. They may become demanding, suspicious, upset or disoriented, see or hear things that are not there and believe things that aren't true. Or they may pace or wander around the house when others are sleeping. http://www.alzla.org/dementia/sundowning.ht ml Alzheimer s Assoc of LA Sundown Syndrome Experts suspect that the problem of late afternoon confusion, which is sometimes called "sundowning," or "sundown syndrome," may be due to these factors: An Alzheimer pt can't see well in dim light & becomes confused, or may have a hormone imbalance or a disturbance in his/her "biological clock," or gets tired at the end of the day and is less able to cope with stress, or is involved in activities all day long and grows restless if there's nothing to do in the late afternoon or evening. A caregiver can communicate fatigue &stress to the Alzheimer patient and the person becomes anxious. Irene Mueller, MLS, RHIA 6

Sundown Syndrome Since this is a manifestation of dementia, does the patient have a diagnosis of some kind of dementia? Before we complete coding, I need to know if there is a dx of dementia? What is the difference between follow-up, status, examination? I have a hard time on these, because the doctors will put down status of something and I never find the code there, but I will under Follow-up, Examination and sometimes under Aftercare? So when do you use these? Or what are the definitions of these to maybe help me know when they should be used. Logistics Please complete the evaluation form Questions about ICD-9-CM diagnosis coding sent to my email through May 1 st, will be answered Irene Mueller, MLS, RHIA 7

imueller@wcu.edu Irene Mueller, MLS, RHIA 8